social determinants of health report

8/3/2019 Social Determinants of Health Report

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W O R L D H E A LT H O R G A N I Z AT I O N R E G I O N A L O F F I C E F O R E U R O P EScherfigsvej 8, DK-2100 Copenhagen , Denmark Telephone: +45 39 17 17 17 Fax: +45 39 17 18 18

E-mail: [email protected] Web: http://www.euro.who.int/en/who-we-are/governance

Regional Committee for Europe EUR/RC61/Inf.Doc./5Sixty-first session

Baku, Azerbaijan, 1215 September 2011 2 August 2011

Provisional agenda item 6(a) ORIGINAL: ENGLISH

Interim second report on social determinants of health and the health divide in the WHO

European Region


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Contents

pageForeword ......................................................................................................................................... iii Contributors ..................................................................................................................................... iv Executive summary ......................................................................................................................... vi 1. Overview ...................................................................................................................................... 1

1.1 Introduction ........................................................................................................................... 1 1.2 Scope of the review ............................................................................................................... 2 1.3 The policy context ................................................................................................................. 2

2. Health and its social determinants in the WHO European Region .............................................. 4 2.1 Health and inequalities in Europe ......................................................................................... 4 2.2 Trends.................................................................................................................................... 8 2.3 Social gradient within countries ............................................................................................ 9 2.4 Conceptual framework ........................................................................................................ 10 2.5 Applying the framework to understand the time trends in the WHO European Region ..... 15

3. European review of the social determinants of health and the health divide ............................. 18 3.1 Structure of the review and the approach to be taken ......................................................... 18 3.2 Task groups ......................................................................................................................... 18 3.3 Activities ............................................................................................................................. 18

3.3.1 Promising practices and country experiences ............................................................. 19 3.3.2 Consultation ................................................................................................................ 19 3.3.3 Examination of future trends in inequalities in health ................................................ 19

4. Emerging themes ........................................................................................................................ 20 4.1 Emerging thinking on themes ............................................................................................. 20 4.2 Thematic areas and issues ................................................................................................... 20

4.2.1 Key concepts ............................................................................................................... 20 4.2.2 Organizations and governance .................................................................................... 23 4.2.3 Interventions and policies ........................................................................................... 24 4.2.4 Wider agendas ............................................................................................................. 26 4.2.5 Economic issues .......................................................................................................... 27

References ...................................................................................................................................... 28 Annex 1. Key messages reported in phase 1 of the review ............................................................ 32 Annex 2. Review of systems, processes and contexts affecting action on the social determinantsof health .......................................................................................................................................... 33 Annex 3. Summaries of the interim reports of the task groups ...................................................... 47

World Health Organization 2011

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The designations employed and the presentation of the material in this publication do not imply the expression of anyopinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory,city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on mapsrepresent approximate border lines for which there may not yet be full agreement.The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned.Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.All reasonable precautions have been taken by the World Health Organization to verify the information contained inthis publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall theWorld Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization.


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Foreword

Reducing health inequities is crucial for the European Region as a whole and is central to myagenda. One of my first actions on assuming the post of Regional Director in 2010 was to inviteMichael Marmot to chair a review of the social determinants of health and the health divide inthe European Region.

This review will inform the new European policy for health Health 2020. It will accelerateaction on socially determined health inequities by developing policies that work in low-,middle- and high-income countries. It draws on best practices, examples and experience of addressing social determinants of health and health inequities in the Region and how to take thisto scale. One of the key goals of the review is to identify what works and how to implement itacross the diverse context of the European Region.

Health is a key and unique resource for the European Region of today and tomorrow. It is aresource that must be nurtured. It is a resource that is much needed and that will help Europe to

be more united and stronger in dealing with its present economic and social difficulties.Can we perform better in promoting health in the European Region? Can we reduce healthinequities by levelling up the health status of the weakest segments of our population and acrossthe social gradient? Can we, with our efforts to promote population health, provide added valueto the social, economic and human development of our countries, regions and cities? I firmly believe that we can.

The evidence provided, the promising practices highlighted together with an in-depth discussionof the implications of the recommendations of the review in the specific context of our 53Member States will surely help to make progress in translating scientific findings into concrete policy action. This is my hope and my expectation as we work to address the health gap across

the Region.This interim second report already outlines some of the areas emerging as key. These include afocus on health assets, addressing processes that increase peoples vulnerability and the whole-of-government approach.

I urge you to read this report and to provide your comments and feedback. Personally, I amexcited to see the progress presented here and look forward to the final report andrecommendations at the sixty-second session of the WHO Regional Committee for Europe inMalta.

Zsuzsanna JakabWHO Regional Director for Europe


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Contributors

ChairProfessor Sir Michael Marmot, University College London, United Kingdom

Senior AdvisersProfessor Guillem Lopez Casasnovas, Pompeu Fabra University, Barcelona, SpainProfessor Zsuzsa Ferge, Eotvos University and Hungarian Academy of Sciences, Budapest,HungaryProfessor Ilona Kickbusch, Graduate Institute of International and Development Studies,Geneva, SwitzerlandProfessor Johan Mackenbach, Erasmus University Rotterdam, the NetherlandsProfessor Tilek Meimanaliev, Executive Director in the Central Asia AIDS Control Project,Bishkek, Kyrgyzstan

Professor Amartya Sen, Harvard University, Cambridge, United States of AmericaBolat Sadykov, Executive Secretary of the Ministry of Health, KazakhstanProfessor Vladimir Starodubov, Deputy Minister of Health and Social Services of the RussianFederationProfessor Tomris Turmen, University of Ankara Medical School, TurkeyProfessor Denny Vger, University of Stockholm, SwedenProfessor Barbro Westerholm, Member of Parliament, Stockholm, SwedenProfessor Margaret Whitehead, University of Liverpool, United Kingdom

Ex-officio members of the senior advisors group:Dr Agis Tsouros, WHO Regional Office for Europe, Copenhagen, Denmark Dr Roberto Bertolini, WHO Regional Office for Europe, Copenhagen, Denmark Michael Hubel, DG SANCO, European Commission

University College London SecretariatDr Jessica AllenDr Ruth BellEllen Bloomer Professor Peter Goldblatt

WHO Regional Office for Europe Secretariat

Christine BrownDr Johanna Hanefeldsa NihlnDr Piroska OstlinSarah SimpsonIsabel Yordi


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Task group chairs topic group (TG) and cross-cutting groups (TC)

TG1: early years, education and the family Naomi Eisenstadt, University of Oxford, United KingdomProfessor Alan Dyson, University of Manchester, United Kingdom

TG2: employment and working conditions, including occupation, unemployment and migrant workersProfessor Johannes Siegrist, University of Duesseldorf, Germany

TG3: disadvantage, social exclusion and vulnerabilityProfessor Jennie Popay, University of Lancaster, United Kingdom

TG4: GDP, taxes, income and welfareProfessor Olle Lundberg, University of Stockholm, Sweden

TG5: sustainability and communityAnna Coote, New Economics Foundation, London, United Kingdom

TG6: preventing and treating ill healthProfessor Witold Zatonski, The Maria Sklodowska-Curie Memorial Cancer Center and Instituteof Oncology, Warsaw, PolandDr Gauden Galea WHO Regional Office for Europe, Copenhagen, Denmark

TG7: gender Professor Maria Kopp, Semmelweis University Budapest, Hungary

TG8: older peopleProfessor Emily Grundy, London Scool of Hygiene and Tropical Medicine, United Kingdom

TC1: economicsProfessor Marc Suhrcke, University of East Anglia, Norwich, United Kingdom

TC2: governance and delivery systemsDr Erio Ziglio, WHO European Office for Investment for Health and Development, Venice,ItalySir Harry Burns, Chief Medical Officer for Scotland, Edinburgh, United Kingdom

TC3: global factorsProfessor Ronald Labonte University of Ottawa, Canada

TC4: equity, equality and human rightsProfessor Karien Stronks, University of Amsterdam, The Netherlands

TC5: measurement and targetsProfessor Martin Bobak, University College London, United KingdomDr Claudia Stein, WHO Regional Office for Europe, Copenhagen, Denmark


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Executive summary

Social justice is a matter of life and death. It affects the way people live, their consequentchance of illness, and their risk of premature death.

Commission on Social Determinants of Health. Closing the gap in a generation: health equity throughaction on the social determinants of health. Final report of the Commission on Social Determinants of Health . Geneva, World Health Organization, 2008(http://www.who.int/social_determinants/resources/gkn_lee_al.pdf, accessed 10 July 2011).

There are major health inequalities1 within and between countries in the WHO EuropeanRegion. The average life expectancy differs between countries by 20 years for men and 12 yearsfor women. Within countries, the levels of both health and life expectancy relate to and aregraded by social and economic position. The lower a persons social position, the worse is his or her health. Everyone except the people in the very highest social and economic positionsadversely experiences some degree of inequality in health.

Most health inequalities are avoidable by reasonable means, and reducing them is a matter of social justice. Perpetuating inequities in health is not acceptable. Action to reduce inequitiesmust be a priority for the WHO European Region, and this is why the WHO Regional Director for Europe commissioned this review of social determinants of health and the health divide inthe European Region.

Progress since 2010

This interim second report sets out the approaches to tackling health inequities that haveemerged from the work undertaken since WHO published the Interim first report on social determinants of health and the health divide in the WHO European Region in September 2010as part of the review. This report further describes some of the Regions inequalities that wereset out in the first report.

Key developments reported are: the reviews conceptual approach to the causes of health inequities and the policies and

processes required to tackle these; analysis of recent time trends in the WHO European Region; identification of the key themes and issues that have emerged from the work of topic-

specific and cross-cutting task groups so far and that will underpin the formulation of recommendations to be made by the review;

emerging thinking on the role WHO, health ministers and other important actors can playin promoting health equity for current and future generations by promoting fairer andmore sustainable societies; and

how the review fits into wider global action on the social determinants of health and thenew European policy for health Health 2020.

1 This report refers to systematic variation in health or social conditions as inequality. Wheninequalities are avoidable by reasonable means, this report uses the term inequity in accordance withthe Commission on Social Determinants of Health.


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Context

Health inequalities are not a new phenomenon, but new understanding of their origins andevidence on successful and unsuccessful interventions to tackle them continues to grow. Thisreview builds on previous reviews of health inequities, especially the WHO Commission on

Social Determinants of Health. The final report of the Commission,Closing the gap in a generation , concluded that achieving health equity requires action on the conditions in which people are born, grow, live, work and age and the structural drivers of these conditions at theglobal, regional, national and local levels. Ill health is not simply bad luck or the result of lack of health care but, as the Commission concluded, results from a toxic combination of poor social policies and programmes, unfair economic arrangements and bad politics and from theunintended and unanticipated consequences of other policies. Inequalities in the quality of earlyyears, levels of education, employment status, welfare and health systems, level of income, the places where men, women and children live, the norms and values of society includingattitudes concerning gender and ethnicity all contribute to inequities in health. They areknown as the social determinants of health.

Reducing health inequities requires action to reduce inequities in the social determinants of health. This is a priority, both because health inequities have significant social and economiccosts to individuals and the wider society and because the social determinants that lead to thesehealth inequities have their own costs, in terms of societal and community well-being, levels of social cohesion and economic development. Equal right to health is an important principle andis explored further in this review.

The ambition of the Commission on Social Determinants of Health was to create a globalmovement. Encouragingly, evidence clearly indicates that a global movement to tackle thesocial determinants of health is gathering momentum. Following a resolution at the WorldHealth Assembly, WHO and the Government of Brazil will host the World Conference onSocial Determinants of Health in Rio de Janeiro, Brazil in October 2011; many nationalgovernments have taken initiatives; civil society organizations and academic institutions areworking actively on the social determinants of health agenda; and there are many examples of concerted local actions.

The WHO European Region has put social determinants and health equity at the centre of itsrevitalized public health agenda by establishing this review of social determinants of health andthe health divide in the Region. The review will inform the new policy for health for theEuropean Region, Health 2020, as will a companion study on governance for health in the 21stcentury. The findings and recommendations of the review will be of global importance becausemany of the problems of health inequity seen around the world are present within the EuropeanRegion.

This review is needed urgently for many reasons. First, significant health problems must beaddressed. The health divide across the European Region continues to be unacceptably large. There

is no good biological or genetic reason why there should be a 20-year gap in lifeexpectancy between countries in the Region.

There are persistently large, and in some case growing, health inequalities withincountries as improved social conditions lead to better health, the benefits are sharedinequitably.

The global economic downturn has profound importance for the health and well-being of populations and is likely to worsen health inequity. The people who are already mostexposed to vulnerability and disadvantage feel the effects of the global economicdownturn more strongly, similar to the effects of natural disasters.


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Sustaining a growing ageing population across the European Region requires increasingthe focus on prolonging good health and well-being throughout the life course. Thisespecially emphasizes taking a life-course approach to achieving equity in health andwell-being and being responsive to the gender issues involved in health and survival.

Action on the social determinants of health is required to effectively deal with thecontinued toll from communicable diseases in many areas and the inequalities in their distribution.

Societies and global organizations need to respond to climate change and the rapiddepletion of natural resources, which threaten catastrophic consequences for health andalso have the most negative effects on people who are already most disadvantaged.Business as usual is not an option for the social and economic arrangements in theEuropean Region; the actions required to achieve health equity and environmental justiceneed to be brought together.

The reasons for taking immediate action are equally compelling.

The Commission on Social Determinants of Health provided the global evidence for whatcan be done to improve health equity, but the evidence and recommendations of theCommission on Social Determinants of Health need to be translated into a form suitablefor the diversity of countries that make up the European Region.

As one example, the Marmot Review of health inequalities in England, commissioned bythe Government of the United Kingdom, is now being implemented in the constituentcountries of the United Kingdom. Lessons from this and the accumulating evidence andexperience from Denmark, Hungary, Lithuania, Norway, Poland, Republic of Moldova,Scotland, Serbia, Slovenia, Spain, Sweden and other countries need to be synthesized,lessons learned and applied across the European Region. The experiences of all countriesacross the Region will shape and inform the content and recommendations of the review.

There are also strong examples of action at the subnational level. The WHO EuropeanHealthy Cities Network, for instance, can help to show that local action can make adifference locally. Cities such as Malm in Sweden and regions such as Murska Sobota inSlovenia and Kosice in Slovakia are developing and implementing multisectoral andstakeholder plans on the social determinants of health. These will feed into the review ina timely way, using newly available evidence.

Local-level action is key to addressing the social determinants of health, with its proximity to peoples lives and experiences. However, it is frequently constrained bynational and global economic influences and power relationships. As a result, local action as long as it remains local is limited in changing the underlying influence anddistribution of power, money and resources that perpetuate health inequity in society. For

this reason, a concerted, multi-level approach is required in the process of developing,implementing and reviewing policy. This is needed to produce sufficient coherence, scaleand intensity of actions capable of transforming the social gradient in health.

Action on the social determinants of health contributes to producing other social benefitssuch as well-being, improved education, lower crime rates, more sustainablecommunities, balanced and sustainable development and improved social cohesion andintegration. For example, early-years skills gained by the time a child starts school arecrucial to self-esteem, motivation, friendships and long-term health and well-being. Inthis way, action on the social determinants of health demonstrates that investment for health equity can directly contribute to attaining other sectoral and government goals andchallenges the notion that health drains public resources.


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Leadership for health

The evidence is clear: action to reduce health inequity and to promote health equity requires thewhole of government and society to be involved. This includes the health system together withstakeholders and sectors within and beyond the boundaries of the health system. This sets both

the imperative and opportunity to govern for health as a common and shared priority, nationallyand locally. As the companion study on governance for health in the 21st century indicates,Health ministers, permanent secretaries, secretaries of state and the like have a key role in goodgovernance for health by engaging in transformational leadership within government. Withinthis context, WHO, health ministers and the wider (public) health community have a key role to play in mobilizing calls for fairer and more sustainable societies that will foster health equity for current and future generations.

This can be achieved in four main ways.

First, as advocates: population health and levels of inequality in health measure how wellsocieties are functioning. Seen in this light, every sector is a health sector, because each socialsector profoundly influences health and well-being. By calling for action to promote healthequity, health ministers not only drive reductions in health inequities but also become engagedin an ethical endeavour creating fairer societies that meet the needs of all, especially thosewho are most severely affected by exclusionary forces and are disadvantaged anddisempowered.

Second, much should be done within the health system to emphasize core public healthactivities more strongly such as health promotion, disease prevention, intersectoral workingand ensuring equitable access to health care.

Third, health ministries, WHO and others in the health sector need to be active in generating the best available evidence and knowledge of what works to reduce health inequities, in monitoringthe effects of actions taken across society and in using this intelligence to strengthen systemsand capacity to govern better for health and health equity.

Fourth, there is a global dimension. Political, social and economic policies have transnationaleffects. European policies affect the fair distribution of health between and within countries of the European Region and of countries outside the Region. These include the policies of theEuropean Commission, the donor community and international agencies and foundations.Health leaders need to advocate a social determinants approach in understanding the causes of health inequities in these international policy arenas. As advocated by the Commission onSocial Determinants of Health, health equity should be at the heart of all policy-making.

Emerging thinking on themes

The recommendations of the review are likely to emerge from the following themes and issuesidentified so far by the task groups in their preliminary analysis of available evidence.

Key concepts

The key emerging concepts of the review are as follows. Assets and vulnerability resulting from the social determinants of health are at the centre

of the conceptual approach. Social integration and cohesion are linked to the social determinants of health and health

inequity. Vulnerability, inequity and the rapid speed of social and economic change are related.


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A human rightsbased approach to health equity is needed. How does variation in well-being relate to health inequalities? The social gradient in health should be reduced by reducing inequities in society and by

taking specific actions across the social gradient. Related to the above, the approach of proportionate universalism should be further

developed. Concerted action is needed across the life course and across all the sectors influencing the

social determinants of health. Gender continues to be an issue in all countries, influencing the risks and opportunities of

men and women throughout their lives, but it looms particularly large in some countriesin the Region.

The review is concerned with excluded groups, but it is more helpful to view exclusion asa process than to focus on who is in and who is out.

By focusing on exclusion as a process, the link between social gradient and specificgroups can be more clearly identified.

Organizations and governance

The key themes relating to organizations and governance are as follows. In addition to traditional organizational interventions, co-production with families and

communities is essential. The review will develop a clearer conception of the appropriate levels at which policy

changes and interventions should be led.

The role of the private sector is important but too often ignored, and this area is a major challenge.

Interventions and policies

The key themes relating to interventions and policies are as follows. Some policies and interventions clearly exacerbate health inequities. Policies will be examined for their effect on the whole social gradient in health. Contextually relevant interventions need to be identified across the diversity of countries

in the European Region. A classification is needed of the types of interventions and policies that are required to

reduce inequities. Action needs to be taken based on the demographic profile of inequalities.

Wider agendas

The key themes relating to wider agendas are as follows: the role of global processes and influences; making links with the agenda for climate change and environmental sustainability; and

empowering civil society.


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Economic issues

The key themes related to economic issues are as follows. Evidence is needed on the social and economic costs of inequities in health. The economic costs and benefits of action on social determinants need to be calculated. Mainstream budgets and investment instruments need to be adjusted to accommodate

action on the social determinants of health bending the spend.

Outline of the main interim report

The main report summarizes the scale of health inequalities in the European Region, recenttrends in the health divide and evidence on the scale of health inequalities within countries. Theconceptual framework being used in the review to describe the social determinants of healthacross the Region and develop recommendations for addressing inequities is set out. This isillustrated by using the framework to understand recent trends in the Region.

The report describes the structure of the review, the approach being taken to arrive at therecommendations and the activities that will be undertaken to validate and strengthen theserecommendations, such as case studies and a consultation process.

The review is being informed by 13 task groups that are undertaking work building on existingknowledge and proposing effective strategies for action in key areas relating to health. Eighttopic groups are each covering one or more of the key social determinants of health in theEuropean Region and/or key stages of the life cycle. A further five cross-cutting groups are eachfocusing on issues that span across two or more of the topic groups. This report describes thescope of each task group and any emerging proposals or recommendations at this stage of their

work.The report concludes with a synthesis and overview of the themes and issues that have emergedfrom the work to date.


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1. Overview

1.1 Introduction

Based on concern about levels of health inequities across the European Region and to ensurethat equity and social determinants of health are at the heart of the new European policy for health Health 2020, the WHO Regional Director for Europe, Zsuzsanna Jakab, commissionedthe European review of social determinants of health and the health divide. The Europeanreview has social justice at its heart and is bringing together the best evidence to lead toimplementation of policies to address social determinants of health across all WHO EuropeanMember States. The review builds on the work of the Commission on Social Determinants of Health (1). The aim of the European review is to develop the findings of the Commission onSocial Determinants of Health so that they can be applied in all the countries in the EuropeanRegion, taking account of the very different social and economic situations in countries acrossthe Region. WHO set up the Commission on Social Determinants of Health in the spirit of social justice, with the recognition that inequalities in health within and between countries arelargely avoidable. The starting-point for the Commission on Social Determinants of Health wasthat a global difference in life expectancy between countries of more than 40 years and thestriking social gradient in health within countries is unjust.

The Commission on Social Determinants of Health concluded that the key determinants of health inequities lie in a toxic mix of poor social policies and programmes, unfair economicarrangements and bad politics. The distribution of power, money and resources and the verydifferent conditions in which people are born, grow, live, work and age constitute the socialdeterminants of health.

Despite Europes overall wealth, it is a region with stark inequalities in health. Life expectancyat birth differs by 16 years between the countries with the highest and lowest life expectancy inthe European Region, with men and women having different experiences. Male life expectancyat birth varies by 20 years between countries compared with 12 years for women. Evencountries with similar levels of wealth and development differ substantially in terms of lifeexpectancy. Life expectancy also differs considerably within countries. The people with greater social and economic advantage have better health and live longer than people with lessadvantage. The groups most severely affected by exclusionary processes, such as Roma andmigrant workers, experience especially significant health disadvantage. The social and healthchallenges across the Region are immense but, as the evidence shows, they are not impossible totackle.

The Commission on Social Determinants of Health brought together the evidence on socialdeterminants of health and made recommendations on the action needed to tackle healthinequity within and between countries. As the reach of the Commission on Social Determinantsof Health was global, applying its findings to specific contexts will take detailed work. Onesuch example was the review of health inequalities in England commissioned by theGovernment of the United Kingdom(2) . This review brought together experts, policy-makers, practitioners and advocates to use new evidence, in the light of the Commission on SocialDeterminants of Health, to develop policies and promote implementation of the reviewsfindings and recommendations. The report was published in 2010 as Fair society, healthy lives (2). It concluded that putting fairness at the heart of all decision-making across the whole of government would improve health and reduce health inequalities. Its recommendations coveredsix domains reaching across all the major social determinants of health. Its findings are beingimplemented in local areas and regions all around England and are influencing policy in Northern Ireland, Scotland and Wales. In England, the governments recent white paper on


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public health(3) indicated that it sees the need to tackle the social determinants of health andadopts the life-course framework used in Fair society, healthy lives (2) for doing so.

1.2 Scope of the reviewThe review draws on the best available evidence that is applicable to the European Region.Based on this evidence, the review proposes effective interventions, governance arrangementsand policies at the regional, national and local levels that will reduce inequities in health bytaking action on the social determinants. Another key aim of the review is to support andaccelerate knowledge, capacity and governance systems for equity in health across the Region.There is currently uneven progress within and across countries in identifying the scale of the problem, translating evidence into practice and in implementing action with the scale, size andintensity needed to be effective. These differences exist even among countries with similar development conditions and governance systems, suggesting that they are amenable to actionand that progress can be made.

This interim second report sets out the approaches to tackling health inequities that haveemerged from the work undertaken since WHO published the Interim first report on social determinants of health and the health divide in the WHO European Region (4) in September 2010 as part of the review (Annex 1).

1.3 The policy context

The findings of the review will inform the new European policy for health, Health 2020, whichis a platform for realizing the health potential of the WHO European Region. The review willdevelop recommendations for implementation that feed directly into policy action across theEuropean Region.

The planned goals of Health 2020 are: to achieve better health for the European Region and its people; to increase equity in health and accelerate progress on achieving the right to health; to make health an endeavour for all of society; to enhance regional and global awareness of and action for health and the determinants of

health; and to develop suggested solutions, tools, evidence, guidance and partnerships that support

health ministries, together with other stakeholders, in putting in place national policies,services and governance arrangements that realize their societies health potential on anequal basis.

Health 2020 is a collaborative initiative between Member States and their health-relatedinstitutions to strengthen existing evidence, expertise and support for action on achieving better health for the European Region. It aims to bring the Region closer to the ideal of better healthfor the next decade by giving expression to health across the whole spectrum of government policy-making at the local, regional, national and European Region levels. Health 2020 will build on and add value to existing developments underway by WHO and its partners, includingthe Tallinn Charter: Health Systems for Health and Wealth(5), and the European Commissioncommunication on solidarity in health(6) in 2009. Annex 2 describes these in more detail.


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The review of social determinants of health and the health divide in the WHO European Regionis an expression of commitments following a resolution passed by the World Health Assembly.Resolution WHA62.14 on reducing health inequities through action on the social determinantsof health (7) supports the findings of the Commission on Social Determinants of Health, inwhich European Member States and partners were active stakeholders. Work arising from thereview will feed into the World Conference on Social Determinants of Health to be held in Riode Janeiro, Brazil in October 2011.

The review is working closely with the European Commission to promote the uptake of itsrecommendations by European Union (EU) and candidate countries as well as other international actors active in the European Region. Although the review does not exclusivelyfocus on the EU, the review is also considering how the EUs wider social and economic policies and actions affect health inequity both globally and within the EU and neighbouringcountries. Donor organizations and other international organizations and foundations will also be engaged during the consultation phase of the review.

Interest is increasing in moving away from using narrow economic indicators to measure progress towards measuring social benefits and well-being. The Commission on theMeasurement of Economic Performance and Social Progress, set up by Frances President Nicolas Sarkozy and chaired by Joseph Stiglitz, emphasized the need to measure social progressin other than narrow economic terms and to focus on well-being as a measure of social progress(8). The EU and the Organisation for Economic Co-operation and Development (OECD) arealso working on indicators of well-being, and several countries have held consultations onindicators of social progress, within which interest has been expressed about integrating thesewith a social inequity agenda. Ill health and health inequities are clear measures of outcomeconsistent with the call of the Commission on the Measurement of Economic Performance andSocial Progress (8) to measure social progress in ways that matter to the well-being of the population. In addition to health, this review is considering well-being and exploring the

relationships between more direct measures of well-being and health and the benefits anddisadvantages of deploying well-being indicators.


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2. Health and its social determinants in the WHO EuropeanRegion

2.1 Health and inequalities in Europe

Although overall population health has improved, there is significant inequality in health acrossthe Region, notably an overall difference in life expectancy of about 16 years between countries(Fig. 1), with even greater differences when gender and other inequalities within countries areincluded in these comparisons.

Fig. 1. Life expectancy in years for countries in the WHO European Region, 2008 or latest available year

Source: European Health for All database [online database] (9).

As Fig. 2 shows, differences between countries are very different for the two sexes with arange of 20 years for males and 12 years for females. Life expectancy for males is about 47years lower than for females in most of the Region, but life expectancy for males is 12 yearslower than for women in Belarus, Lithuania, the Russian Federation and Ukraine and 13 yearslower in Latvia. In contrast, life expectancy for females is only one year longer than for males inTajikistan.


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Fig. 2. Life expectancy at birth by sex for countries in the WHO European Region, 2008or latest available year

(a) Males

TFYR Macedonia: The former Yugoslav Republic of Macedonia.Source : European Health for All database [online database] (9) .


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(b) Females

TFYR Macedonia: The former Yugoslav Republic of Macedonia.Source : European Health for All database [online database] (9) .


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The average life expectancy in the countries of central and eastern Europe and the countries inthe Commonwealth of Independent States (CIS)2 is lower than in the countries in the western part of the Region (Fig. 1). In the latest data from the WHO European Health for All database(9), female life expectancy at birth was 4.3 years lower in the 12 countries that joined the EUafter May 2004 (EU12) than in the 15 countries that were EU members before May 2004(EU15) (Fig. 3). The difference between CIS countries and the EU15 was more than twice aslarge, at 9.7 years. The corresponding differences for males were more than 50% higher than for females, at 6.9 and 15.0 years, respectively.

Fig. 3. Trends in life expectancy in the EU15, EU12 and CIS, 19802008

(a) Males

Source : European Health for All database [online database] (9) .

2 The CIS consisted of Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, the Russian Federation, Tajikistan, Turkmenistan, Ukraine and Uzbekistan when the data werecollected.


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(b) Females

Source : European Health for All database [online database] (9) .

2.2 Trends

East-west differences in the European Region have changed over time(10) . As Fig. 3 illustrates,the differences have not always been as great as in the past 2030 years. Much of the widening between 1980 and 2008 took place between 1981 and 1994. The gap in female life expectancy between the EU12 and EU15 rose from 3.7 to 5.4 years in this 13-year period and for malesfrom 4.3 to 7.3 years. For the CIS, the gap increased from 5.4 to 9.2 years for females and from8.1 to 13.9 for males. After 1994, the gap for the EU12 narrowed slightly, but the gap for theCIS widened a little more.

These changes need to be seen in a historical perspective. Before the Second World War,countries in the east and west differed substantially. After 1945, mortality declined considerablyin all parts of the European Region until the mid-1960s, but mortality declined more rapidly inthe eastern part of the Region, largely because of communicable disease control and hygiene

and housing improvements. As a result, in the 1960s, the gap in life expectancy betweencountries in the central and eastern part of the Region and those in the western part of theRegion declined considerably. However, between the early 1970s and late 1980s, lifeexpectancy continued to increase in the western part of the Region but stagnated or fell in theeastern part of the Region, mainly because of rising death rates from cardiovascular diseases(11) . This led to a renewed widening of the eastwest gap in life expectancy(10) .

After communism collapsed in 1989, which led to profound societal changes, life expectancydiverged between the countries in central and eastern Europe and those in the Commonwealth of Independent States (CIS). This divergence is most likely to have reflected different patterns of societal transition across CIS and across the countries in central and eastern Europe(10,12,13) .As a result, life expectancy in the CIS countries is falling behind that in the countries in central

and eastern Europe and in the western part of the Region. In particular, as shown in Fig. 2, itremains at 65 years or less for males in five CIS countries. Recent national figures from the


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Russian Federation, not yet included in WHO data, suggest that life expectancy has improvedconsiderably in the past few years, possibly reflecting political, economic and socialstabilization; the most recent figure suggests that life expectancy at birth reached 62.8 years for males and 74.7 years for females in 2009.

The fluctuation in mortality in the CIS in the 1990s is the largest ever observed in any countrywith existing statistics; the increase in mortality in the first half of the 1990s in the RussianFederation alone has been estimated to be equivalent to about 3 million extra deaths above thelong-term mortality level(14) .

2.3 Social gradient within countries

For countries for which data are available, health outcomes have a clear gradient across the population according to such social factors as income, education, social position andemployment(15,16) . Fig. 4 illustrates this by comparing the gradient in self-reported health by

educational level in Latvia and Sweden.

Fig. 4. Percentage reporting their health as being good or very good by householdincome quintile in Latvia and Sweden, 2008

Source : personal communication, Jonathan Bradshaw and Emese Mayhew, University of York, UnitedKingdom, using 2007 data from: European Union Statistics on Income and Living Conditions (EU-SILC)[online database] (17) .

Despite very different levels of self-reported health between Latvia and Sweden, which reflect acombination of perceptions of health in different countries and different levels of signs andsymptoms of ill health, both countries have a notable gradient in self-reported health. A widevariety of studies (18,19) have shown that self-reported health predicts future health well.

Mackenbach et al.(20) systematically compared gradients in mortality inequality among menand women according to educational level by using individual information obtained by the


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Eurothine project from studies in 16 countries in the EU and European Free Trade Association(EFTA). The evidence from this project indicates considerable variation across these countriesin levels of inequality in mortality, based on the length of education of individuals included inthe studies covered (Fig. 5). Inequality was greatest in the countries in central and easternEurope included in the project and least in Italy, Spain and Sweden.

Fig. 5. Absolute inequality (slope index of inequality) in male death rates by level of education in selected EU and EFTA countries

Source : Mackenbach et al. (20) .

2.4 Conceptual framework

The social, economic, political, environmental and cultural factors that shape health across theRegion and within countries are known as the social determinants of health(1) . For theEuropean review, the conceptual framework developed for the Commission on SocialDeterminants of Health(1) is being developed to highlight the main pathways to health and the policies and practices that affect these and are amenable to action that reduces inequities(Fig. 6).


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Fig. 6. The social determinants of health

This framework is intended to guide understanding of inequalities in health between societies aswell as those within. Many between-country inequalities in health may be understood as arising

from the influences of the social determinants of health within countries a country that fails tomeet human needs of large swathes of its population will be a country with poor health. But thesocial determinants of health within countries are affected by influences acting beyond thecountrys borders, in political and economic arrangements, in trade and in internationalrelations. Some parts of the framework in Fig. 6, especially the more distal influences, will beespecially important in between-country health inequities.

The framework provides a summary of what is often referred to as the causes of the causes of poor health. In recent decades, much public health has focused on proximate causes of ill health.In relation to chronic disease, this has meant aspects of lifestyle: smoking, diet, alcoholconsumption and physical activity. The perspective here is that of the Commission on SocialDeterminants of Health(1): that the causes of these lifestyle causes of poor health reside in the

social, legal and political context, broadly conceived. Fig. 6 provides a schematic illustration of the causes of the causes. For simplicity, the figure does not show possible links and feedback loops. These causes start with the societies in which individuals, families and communities arelocated as they grow and develop their structures, governance, norms and values. Thesecharacteristics of societies are influenced by the macro economy and other global forces actingoutside a particular country the nature of trade, aid, international agreements andenvironmental factors, including climate change.

These societal factors and the macro processes operating on them influence the exposure of men, women and children to health-damaging and health-promoting conditions through the lifecourse from pregnancy and early-years development through educational experiences,reproductive ages and relationship to the labour market and income levels during normalworking ages and into later years. Intergenerational effects affect the life course, including butnot restricted to the conditions of the mother and father before conception. The influences that


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operate at each stage of the life course can change the odds or level of exposure or help people beat the odds when exposed. Other factors have an influence in one or more of these waysthroughout the life course. These can be categorized as: attributes that individuals possess age, sex, height, weight, birthplace, the social

conditions of their parents in the prenatal period and through their childhoods, including but not restricted to income, education and employment; the identities society and social institutions ascribe to individuals such as those relating

to gender norms and gender relations, sexuality, ethnicity, nationality and disability; the material and psychosocial conditions of peoples lives including both the start they

had in life in terms of social conditions and material wealth and assets transmitted acrossgenerations and those acquired during their own lives, such as food and water, securityand housing; and

the specific hazards to which individuals are exposed in the womb and throughout their lives, including the risks posed by physical, chemical and biological substances.

The way other people perceive identities frequently leads to the vulnerability, exclusion anddiscrimination experienced by ethnic groups such as Roma populations. Perceptions of identityand differences in social roles linked to gender and education interact with biological attributes.These are key for reproductive and sexual health, which are strongly affected by societalconditions. Some but not all the causes of health differences in these groups with differentidentities are socioeconomic. It is important to understand how biological sex differences andgender-related social determinants of health link to the different patterns of health among menand women.

This causal framework is designed to help think through the interaction between the factors and processes that influence the risk or level of exposure to advantage or disadvantage and thosethat influence the vulnerability and resilience of people, groups and communities when exposed.Together these factors and processes accumulate over time, leading to different levels of various psychosocial attributes among individuals and social conditions in families, communities andsocial groups. This includes developing levels of resilience, capabilities, control and stress inindividuals; in communities it affects levels of social cohesion, social capital, integration andresilience.

These are dynamic, in the sense that the accumulation of positive and negative influencesconstitutes an ongoing process. This process of accumulation leads to the factors that mostimmediately affect health and well-being, characterize people and communities at each point intime and influence the lifestyles and behaviour that people adopt and that are prevalent in thecommunities in which they live. The causal pathways that lead to vulnerability and exposure

and predispose people towards unhealthy behaviour and worse health are not equallydistributed. They lead to the health inequities seen across the European Region the healthdivide between countries and the social gradient between people, communities and areas withincountries.

The unequal distribution of the determinants of health, as described above, stems from the politics and history of countries and areas, the socioeconomic stratification of societies withinthese geographical entities and the unequal distribution of power, prestige, money and resourceswithin and between countries. Social institutions can play a role in creating this unequaldistribution by discriminating between people, groups and communities in the distribution of life opportunities, such as education and entry to and progress within the labour market, basedon their attributes, identities and material conditions. This has an important divisive effect on

the subsequent accumulation of relative social and economic advantage. The extent to whichinequalities may be counterbalanced in a society or community relies on equity a sense of


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what constitutes social justice, human rights and equality. Underpinning this approachconceptually is the importance of empowerment: material, psychosocial and political. Havingthe material requirements for a decent life, having control over ones life and having politicalvoice and participating in decision-making all create good health. These two contradictoryinfluences, inequity versus equity and social justice, are shown as opposing forces on either sideof Fig. 6.

Fig. 7. Policies and practices

The political and historical situation in a country, its policies and practices, the cultural andsocial norms of a society and its government, at every level, set the context in which the socialdeterminants operate and hence are potentially amenable to change. They vary across countriesand societies. If correctly channelled, changes in policies, practices and norms can lead toreductions in health inequities and improvements in health for all in a country, as well as andgreater community cohesion and well-being. If not, they can lead to widening inequities andworse health and well-being. The causal pathways for an individuals health are complex andlong term. Tackling health inequity requires the participation of all of government and of grassroots social movements as well as other sections of society. The cumulative effect of interventions across society has a cumulative impact in reducing health inequities andimproving overall health within each country.

The processes and systems that need to be aligned are shown in Fig. 7. The tensions across thesesystems are such that aligning policies, processes and movements to support better healthoutcomes is no easy task. It is highly organizationally complex both across the systems shownin Fig. 7 and between the different levels of governance and delivery from transnational

organizations through local and community organizations. It is also often not in the commoninterest of those concerned. For example, whatever else is achieved by improving education,higher levels of attainment across the gradient increase competition for jobs at the middle and


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higher ends. Economic growth and climate change policies can be in conflict. The review willexplore and recommend ways of effective working across systems and structures.

The social and political context for the policies that affect individual health, while includingthose bearing directly on health, also includes social, fiscal, trade and environmental policies aswell as globalization, for the reasons described above. These policies are implemented throughthe relevant systems education, family, social welfare, health care, tax, labour market, spatial planning, transport and crime and community safety at each level of governance and delivery.Strategies need to be operationalized at every level, both through formal government sectors andthrough social movements. The levels at which these strategies need to operate run from thefamilies, neighbourhoods and communities in which people live to the local, regional, nationaland international agencies that influence their lives. Action at all these levels and types of governance also needs to involve civil society and social movements and take account of the private sector. As indicated earlier, ideally these actions should be taken together rather than inisolation.

There needs to be co-production between systems and between agencies from bothgovernment and civil society charged with implementing policies and practices. Communities,social organizations and institutions affected by these changes also need to be involved in co- production change should be carried out with and not to people and their communities.

Action that takes place in sectors other than health, with the primary intention of addressingoutcomes relevant to these sectors, frequently affects both the social determinants of health andhealth equity. Examples include education, social welfare and the environment. Where agendascan be aligned, this will produce multiple benefits. The policies and interventions of other ministries and agencies, as well as those of the health system, should be strengthened as a result.Efforts to mitigate climate change and conserve natural resources, for instance, can also affecthealth for example, more active travel, more open spaces and better insulated homes.

Environmental and health agendas should be aligned where possible. Similarly, reducingunemployment by providing jobs with good working conditions will have multiple benefitsincluding effects on health inequalities, improving social integration and cohesion and reducing poverty. This does, however, pose significant challenges when jobs are scarce or are onlyavailable in small business enterprises. In addition, as previously indicated, alignment iscomplex, and there are often tensions between policies and the organizations that design anddeliver them. However, health equity in all policies is a central principle through which toembed and deliver greater health equity across social policies.

In applying these approaches, a sequence of preliminary steps is required, using two lensesthrough which policy implementation needs to be viewed. First, the equity lens ensures that the policies are, in principle, those that will lead to greater equity in health and its determinants.

Second, the evidence lens provides a focus for understanding the nature and magnitude of thesocial gradients to be addressed and enables any reduction in the gradient to be monitored,measured and interpreted and progress against any targets set assessed. This focus onmonitoring the evidence throughout also enables policies to be adapted so as to ensure greater effectiveness. It also provides a means of auditing and evaluating policies against the aspirationof equity in all policies and assessing the gap between current levels of inequity and theaspiration of achieving health equity.


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2.5 Applying the framework to understand the time trends in the WHOEuropean Region

Economic transition in eastern Europe has been associated with factors likely to widen healthinequities and worsen overall health(2123) , specifically: initial reductions in gross domestic product (GDP) to between 50% and 85% of the 1989

levels, affecting 400 million people and barely recovering by 1999; a rise in poverty and inequality that persists today; increased alcoholism, smoking and drug use; disruption of health care and child care; a transition from unemployment rates of near zero to double digits; and disruption of a guaranteed standard of living perceived to be adequate.

These factors provide the background to the several explanations related to this conceptualframework that have been proposed for the rapid changes in mortality and other dimensions of health that were accompanied by a rapid increase in social inequality in health in manycountries in the European Region(24) . The most commonly discussed broad groups of explanation are health behaviour such as smoking, alcohol consumption and diet andsocioeconomic and psychosocial factors. Both groups of factors are consistent with the fact thatmuch of the difference in mortality between the eastern, central and western parts of theEuropean Region and between lower and higher socioeconomic groups within countries mainlyresults from cardiovascular diseases and injuries and violence. An important role for health behaviour and socioeconomic and psychosocial factors in both these causes of death is plausible.

The discussion that follows illustrates the importance of proximal influences, such as lifestyle,on trends in ill health. Gauging the magnitude of the role played by these influences contributesto understanding trends. The approach taken by the review, consistent with the conceptualframework above, is that these lifestyle causes must be put in the context of the causes of thecauses. This is particularly important in considering the policy response. A social determinantsframework is essential to taking action on these major causes of health inequity within and between countries.

Accidents, injuries and violence may be important in emerging economies and those that haveexperienced transition, when deregulation has occurred, especially if health and safety lawshave been weakened. For example, Lithuania has one of the highest levels of gross nationalincome per person in central and eastern Europe and the CIS. It ranked fourth among thesecountries in 2005. However, despite falling death rates, Lithuanians still have a high risk of dying from external causes excluding exposure to smoke, fire and flames(9) with thehighest mortality rate from motor vehicle traffic accidents in the WHO European Region inrecent years, the second highest from all transport accidents and the third highest fromaccidental drowning. Violence is also a significant cause of death.

Smoking, high alcohol consumption and an unhealthy diet have been widespread in central andeastern Europe and the CIS for several years. An indirect estimate suggested that, in the RussianFederation in 1990, about 30% of all deaths among males and about 4% of deaths amongfemales were attributable to tobacco. Among men and women aged 3569 years, these proportions were 42% and 7%, respectively(25) . Given the lack of any decrease in smokingamong men and an increase in smoking among women(26) , the importance of smoking for mortality among women in the CIS has probably increased further. Within populations, tobaccosmoking shows an inverse social gradient (with a higher prevalence of smoking among people


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of lower social status), which is stronger among men, in central and eastern Europe(2628) .This is likely to contribute to the social gradient in ill health(29,30) . However, the role of smoking among women is less consistent, and the contribution of smoking to inequalities inhealth probably differs by the countrys stage in the epidemiological transition from the predominance of communicable diseases to noncommunicable diseases.

Alcohol has similarly been linked with high mortality in central and eastern Europe and the CIS(31,32) , and heavy drinking, particularly among men, has probably contributed substantially tofluctuations in mortality during the economic transition in these countries(33,34) . However, thesocial distribution of alcohol consumption in central and eastern Europe and the CIS isinconsistent(3537) , as it is in many countries in the western part of the European Region(38) .Alcohol contributes to the social gradient in mortality among men in Finland and Sweden(39,40) , but its role in other countries remains to be clarified. For example, the patterns of bingedrinking and the total amount consumed in a year differ both within and between countries,resulting in variability of health outcomes. Alcohol also plays a significant role in gender differences. It contributes significantly to the gender gap in life expectancy in many countries,especially in the eastern part of the European Region. It also plays a key role in the sexual behaviour of both men and women(41) and in domestic and sexual violence experienced bywomen (42) .

High levels of obesity have been common in central and eastern Europe and the CIS, particularly among women(43) . Similar to other types of behaviour, the relationship betweensocial status and obesity depends on the stage of the nutritional transition reached by a society(44) . For instance, obesity is initially most common among affluent and educated people, because they are the first to adopt new lifestyles and technologies and because they can afforddiets high in animal fat which are more expensive. However, as observed in high-incomecountries and more recently in many middle-income countries, the social gradient in obesityreverses when the obesogenic environment changes, such as wider access to energy-dense and

nutrient-poor food and, in time, obesity becomes associated with poverty and low social status(45,46) . This has happened in western Europe, central and eastern Europe and the CIS. In the1980s and early 1990s, the educational gradient in obesity among men in central and easternEurope was similar to that in low-income countries(43) . However, by the mid-2000s, the malegradient in central and eastern Europe seemed to have changed into the inverse associationtypical of high-income countries, and the CIS does not seem to have any clear educationalgradient in men(47) . Given the dependence that exists between the size and direction of socialgradients in smoking, obesity and nutrition and the stage of the epidemiological transition in agiven country, the contribution of health behaviour to inequities in health at any time is likely todiffer between countries.

As previously indicated, a large body of evidence supports the role of socioeconomic factors in

both long-term and short-term trends in population-level mortality in central and eastern Europeand the CIS (4752) . Among individuals within countries, both in the western and the eastern parts of the European Region, psychosocial factors, such as perceived control of ones life,depression, job stress, low trust and absence of social networks, are all strongly associated withsocioeconomic status. Since several prospective studies(31,5356) have shown an association between many of these factors and mortality and other health outcomes, psychosocial exposureis a plausible mediator of the association between socioeconomic disadvantage and ill health.However, the number of relevant studies in central and eastern Europe and CIS countries isrelatively small, and more are required to reliably quantify the role of psychosocial factors inthese countries.

A third group of commonly proposed explanations of these trends relates to the health system.This is a complex area. For example, most studies rely on classifying the causes of death intothose that are thought to be amenable to health care and those that are not(57) . Several studies


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suggest that inadequate access to effective health services contributes to the high long-termmortality levels in the CIS(58) , especially from coronary heart disease(11,59) , to decliningmortality in the Czech Republic after 1990(60) and to short-term fluctuation in mortality in theRussian Federation(61) . There has been a shift to increasing inequality of access to health carein central and eastern Europe (62,63) , resulting from factors such as service design,accessibility, acceptability, affordability and financing mechanisms. As inequities in health carehave been associated with inequity in health within high-income countries(64,65) , they maywell also contribute to inequities in health within countries in central and eastern Europe andCIS countries. Variation in access to maternal health care, including antenatal care, in manycountries in the European Region(42) has a particularly important effect on infant and maternalhealth and early-years development.

This analysis has illustrated the importance of using the conceptual framework (Fig. 6) tounderstand the development of the current health divide and health inequity in the EuropeanRegion. The magnitude of both health and social determinants differs significantly within and between countries in the European Region. As has been demonstrated, these are related in termsof time trends, spatial distribution and causal pathways. These causes act both at the societallevel, for example during the economic transition in central and eastern Europe, and on thehealth of particular socioeconomic groups or geographic areas. They may operate directly on theindividuals concerned, or their effects may be mediated through health-related behaviour. Moreimportantly, substantial evidence now shows that social determinants acting through the lifecourse, from conception and the early years of life through every life stage, have a cumulativeeffect on health. This results in a graded relationship between social factors, economic positionand health outcomes, both within and between countries. It follows that the magnitude anddirection of these gradients crucially depends on the very varied experiences of the cohorts onwhich the measurement of health outcomes is based.

It also follows that developing a strategy for reducing health inequities requires building on the

conceptual framework and the life-course approach and making explicit the role played byvarious identities and attributes such as gender, ethnicity and disabilities.


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3. European review of the social determinants of health and thehealth divide

3.1 Structure of the review and the approach to be taken

The aim of the review is to propose strategies for action based on the best and most recentevidence. To achieve this, 13 task groups are informing the review by undertaking work to buildon existing knowledge and propose effective strategies for action in key areas relating to health.Eight topic groups are each covering one or more of the key social determinants of health in theEuropean Region and/or key life-cycle stages. Five cross-cutting groups are each focusing onissues that span across two or more of the topic groups. Annex 3 provides more detail about thescope of each task group. The methods of working vary between groups according to the issuesto be addressed. Each topic or cross-cutting task group comprises either a chair or two co-chairsand other independent members, who are all experts in the field.

3.2 Task groupsThe eight topic task groups are as follows:1. early years, education and the family;

2. employment and working conditions, including occupation, unemployment and migrantworkers;

3. disadvantage, social exclusion and vulnerability;

4. GDP, taxation, income and welfare;5. sustainability and community;

6. preventing and treating ill health;7. gender; and8. older people.

The five cross-cutting task groups are as follows:1. economics;2. governance and delivery systems;

3. global factors;4. equity, equality and human rights; and5. measurement and targets.

3.3 Activities

The task groups and the review secretariat are developing the evidence base into clearly defined, practical recommendations and actions to reduce inequities in health across the EuropeanRegion. These range from overarching general recommendations to more local and specificones and encompass policy in all the areas covered by the task groups including healthsystems, methods of measurement and governance.


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To complement the work of the task groups in gathering and formulating practicalrecommendations, the review secretariat will undertake additional tasks to add real-lifeexamples to its recommendations and to act as a reality check on them.

3.3.1 Promising practices and country experiencesCountries experiences and examples of promising practice are used to illustrate significant policies or actions taken to address inequities in health. There will be a range of cases from thelocal, national and European Region levels.

3.3.2 Consultation

A consultation paper is being developed, based on this report and the preliminary reports of thetask groups. This is intended to stimulate debate on the social determinants of health and thereduction of health inequities within and between countries in the European Region. It also aimsto build further political support, policy alliances and capacity for a social determinant approachacross government and partner organizations. This will be linked to the consultations on the newhealth policy for the WHO European Region. Through these processes of consultation anddialogue, a diversity of voices and country perspectives will be reflected in the development of the review, increasing its relevance and robustness as a tool for action to improve health onequal terms in the European Region. At the same time, the process is intended to directlyincrease support for action on the social determinants of health and health equity at the nationaland local levels and to facilitate testing of the policy options developed through the review.

Task groups will submit their final reports between September and December 2011 and,following a stakeholder consultation, a final review report will then be prepared for the sixty-second session of the WHO Regional Committee for Europe in September 2012.

3.3.3 Examination of future trends in inequalities in health

Finally, the review will identify likely future trends in inequalities in health, taking into accountexisting data and other relevant factors. This is likely to include the economic downturn and theassociated cuts in public expenditure and other pressures on policy and politics within and between countries, as this has the potential to influence other social determinants of health. Thedemographics of many countries in the European Region show an ageing population, and thistrend is expected to continue, so this will need to be considered when making recommendations,as will both the effects of climate change and the need to act to reduce carbon emissions.

This section outlines some of the main barriers to and opportunities for reducing healthinequities across the European Region. Subsequent work during the review, including that of thetask groups and consultation responses, will build on this initial analysis and propose effectiveways of creating and maximizing opportunities and overcoming barriers based on the availableevidence.


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4. Emerging themes

4.1 Emerging thinking on themes

This section brings together some of the themes emerging from analysis outlined in previoussections and the work of task groups to identify overarching challenges and particular issues(such as achieving a whole-of-government approach and the role of international organizationsand donor agencies). Where possible, the section identifies emerging themes from the task groups. It examines what can be proposed around the financial and human costs of healthinequity across the European Region (such as the cost of doing nothing) and the potential usesof evaluation to develop costed cases. It outlines some of the challenges arising from the varioushealth inequity issues in low-, middle- and high-income countries and explains the proposals for meeting these challenges in the review.

4.2 Thematic areas and issues

The recommendations of the review are likely to emerge from the following themes and issuesidentified so far by the task groups in their preliminary analysis of available evidence.

4.2.1 Key concepts

4.2.1.1 Assets and vulnerability resulting from the social determinants of health are at the centre of the conceptual approach

As described in Section 2.4, causal pathways that stem from the social determinants of healthcreate vulnerability and exposure that predispose individuals and social groups towards worsehealth. Conversely, some pathways lead to increased development of capabilities, control and

resilience providing individuals and communities with the power to act in their own best interestto strengthen health and well-being, both directly and through healthy lifestyles and health- promoting behaviour.

4.2.1.2 Social integration and cohesion are linked to the social determinants of healthand health inequities

The degree of social integration and cohesion in a society is the product of the same socialdeterminants as is health, and social integration and cohesion may themselves be socialdeterminants of health. It follows that inequalities in the social determinants of health areclosely associated with differing levels of integration and cohesion across the European Region.This observation provides an important way of linking review recommendations and analysis towider concerns across the Region. For example, high levels of unemployment and insecureemployment worsen social insecurity, heighten unrest, intolerance and racism and are bad for health. This gives tackling many of the social determinants of health additional politicalrelevance and urgency. It is potentially useful for health ministers to be able to make that pointacross government and for the EU, WHO and United Nations to have an aligned agenda.

4.2.1.3 Vulnerability, inequity and the rapid speed of social and economic change arerelated

Vulnerability is not an innate characteristic of individuals but a product of the circumstances inwhich people are born, live and work. Particularly toxic combinations of circumstances canadversely affect all but the most resilient people. Among communities living in poverty, suchcombinations are and have always been particularly likely to lead to a range of adverse social


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and health outcomes. However, in periods of rapid social, political and technological change,the conjunction of adverse circumstances can lead to a rapid increase in vulnerability for many people who may have previously led relatively secure lives. The following are examples of increasingly common insecure conditions.

Many forms of employment are insecure. These include seasonal work, temporarycontracts and informal or illegal work. Employment that emerges from labour market deregulation and liberalization, in the

context of new economic policies and globalized competition, is frequently precarious.There are different types of precarious employment, including subcontracting, marginalself-employment, freelancing and similar forms of temporary contracts.

Processes of organizational downsizing and restructuring frequently result in jobinstability and insecurity.

Insecurity is heightened when these insecure forms of employment result in either frequent periods of short-term unemployment or in a period of long-term unemployment.The absence of adequate and appropriate social welfare provision exacerbates the effectsof unemployment.

Irregular migration leads to insecurity, especially when instigated by economicdeprivation, human rights infringements or civil unrest.

Having refugee or asylum status may lead to insecure conditions, especially when thereception in the host country is mixed or mostly hostile.

People and groups of people become insecure and vulnerable when they are exposed tonegative and/or stigmatizing attitudes towards them. This becomes more extreme insituations of economic insecurity, and they become susceptible to rapid shifts in attitudes.For example, the rapid escalation of negative attitudes towards Roma has increased their vulnerability to exclusionary processes. This has reduced their opportunities for obtaining

employment, accessing health and education services and residing in some areas. The complexity and increasing speed at which attitudes are formed and dispersed (partly

but not exclusively as a result of technological change and the rapid globalization of ideas) may increase vulnerability very rapidly.

Rapidly changing social welfare provision leads to insecurity, with a greater lack of certainty about the capacity and breadth of social support systems. Such rapid shiftsexacerbate the increasing vulnerability of groups of people in need of such support.Further, stress, anxiety and other mental health problems are likely to increase as a resultof these rapid changes to social support systems.

Rapid changes compound the difficulty associated with trying to reduce vulnerability for somegroups such as women exposed to domestic violence. The nature of vulnerability changescontinually, as do the groups of people being made more or less vulnerable. In addition, thesystems of support are themselves changing rapidly.

This theme clearly links to the overarching theme of social cohesion and integration.

4.2.1.4 A human rightsbased approach to health equity is needed

Oldring & Jerbi(66) discussed human rights and health.

Today there is growing recognition of the links between health and a wide range of human

rights, as well as a growing appreciation of the right to the highest attainable standard of healthitself. There is broad agreement that health policies, programmes and practices can have a direct bearing on the enjoyment of human rights, while a lack of respect for human rights can have


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4.2.1.8 Concerted action is needed across the life course and across all the sectorsinfluencing the social determinants of health

As the conceptual framework illustrates, the social determinants of health are stronglyinterlinked and act through the life course and intergenerationally. Health inequity cannot be

reduced through one instrument or in a short period of time. It requires concerted action acrossthe various determinants and across the life course, achieved through the actions taken by avariety of sectors and agencies co-producing with communities. As the title of the report of theCommission on Social Determinants of Health(1) indicates, the challenge is closing the gap ina generation.

4.2.1.9 Gender continues to be an issue in all countries, influencing the risks and opportunities of men and women throughout their lives, but it looms particularly large insome countries in the Region

Gender norms and relationships affect the exposure to risk and the opportunities for health of both women and men. Societal values and the distinctive gender identities assigned to men andwomen can both lead to discrimination and adversely influence behaviour. In these variousways, gender influences the other determinants of health throughout the life course to a greater or lesser extent in different societies.

Action is needed in all societies, but the need is greatest where the resulting health differencesare unfair and avoidable and are amenable to intervention.

4.2.1.10 The review is concerned with excluded groups, but it is more helpful to view exclusion as a process than to focus on who is in and who is out

Viewing disadvantage, social exclusion and vulnerability in terms of processes rather than as astate experienced by particular groups will improve the identification of key characteristics of action by governments and other actors that have the potential to exacerbate or positivelyinfluence these processes and hence increase or reduce health inequities. This should enable thereview to produce a framework for identifying principles for action to reduce exclusion and anyassociated health inequities.

4.2.1.11 By focusing on exclusion as a process, the link between social gradient and specific groups can be more clearly identified

In accordance with the definition adopted by the Social Exclusion Knowledge Network of the

Commission on Social Determinants of Health(67) , social exclusion can be regarded ascomprising dynamic, multidimensional processes that are driven by unequal power relationshipsinteracting across four main dimensions economic, political, social and cultural that operateat different levels. These processes result in a continuum of inclusion and exclusion that ischaracterized by unequal access to resources, capabilities and rights and that lead to a socialgradient in health inequities.

4.2.2 Organizations and governance

4.2.2.1 In addition to traditional organizational interventions, co-production with family and communities is essential

A conclusion emerging from many task groups is that traditional organizational interventionsare not always the most successful when, for example, they do not engage communities in

8/3/2019 Social D

social determinants of health report

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